General Information Section:

Age

Occupation

Email

Emergency Contact & Phone Number

Family Doctor & Phone Number

Insurance Company

If you were referred, who was it?

Goal Section:

My goals are:

**Please Note: Reiki does not take the place of medical care. It is recommended that you see a licensed physician or health care professional for any pain, physical or psychological ailment you may have.

Current Medical History:

If yes, please describe:

Medications/Vitamins/Dietary Supplements:

Allergies:

Past Surgical History:

Other not listed:

Please share with me information about your health and wellness, so I may be able to understand and help you achieve your health and wellness goals.

Please describe your lifestyle and what you currently do to be healthy and well:

Please describe any health challenges you currently experience (major concerns as well as bothersome things like headaches, insomnia, etc.)

Are you currently on any medications or supplements?

What do you consider is causing stress in your life right now and what do you do to reduce stress in your life?

Are you on any special diets?

Please describe a typical week with your diet, exercise, and activity.

Do you have any known environmental/food allergies?

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